"The good life" for demented persons living in nursing homes

BACKGROUND: This study investigated which concepts regarding "the good life" are used in mission statements of nursing homes providing care for demented patients. METHOD: All 317 Dutch nursing homes caring for demented patients were asked to participate; of these, 69% responded. Their mission statements were qualitatively analyzed on content. Whether different types of nursing home differed significantly in the content of their mission statements was investigated by means of chi2 analyses. RESULTS: Six main concepts were found that are considered important for a good life: 1) autonomy and freedom, 2) individuality and lifestyle, 3) relationships and social networks, 4) warmth and safety and familiarity, 5) developing capacities and giving meaning to life and 6) subjective experience and feelings of well-being. It was found that mission statements specifically developed for demented patients attach less importance to the concepts 1) autonomy and freedom and 2) individuality and lifestyle, than mission statements which are also aimed at non-demented residents. Most mission statements turned out to be highly eclectic in content. CONCLUSION: Nursing homes with a separate statement for demented residents seem to acknowledge the special position of demented residents and the tension between dementia and the ideal of autonomy. Although the eclecticism found in mission statements is understandable, a coherent view on the good life for demented residents should aim for a sound internal structure, and make choices between values. Only then can mission statements provide real guidance for everyday care.     

Monoclonal antibodies to P2 basic protein and their use in the investigation of some aspects of the Guillain-Barré syndrome

The production and characterization of two mouse monoclonal antibodies (MAbs) raised against human basic protein P2 is described. The two MAbs recognise two non-overlapping epitopes on P2. Using these two MAbs as a probe, a search was made for the presence of anti-idiotype (Ab2) antibodies directed against anti-P2 (Ab1) autoantibodies in sera of patients with Guillain-Barré syndrome (GBS). In sera of twenty GBS patients no such Ab2 antibodies could be demonstrated. Epitopes present on cytomegalo virus- or Epstein-Barr virus-infected cells, which may play a part in triggering GBS, were not recognised by the two MAbs.     

Angioplasty for stable versus unstable angina pectoris: Are unstable patients more likely to get restenosis?

Summary Current evidence with regard to the possible association between clinical expression of coronary disease prior to the time of angioplasty, and the subsequent risk of restenosis following successful dilatation, remains inconclusive.To prospectively compare the incidence of restenosis in stable versus unstable angina pectoris patients, follow-up angiography was performed in 85 percent of patients from a consecutive series with a successful PTCA, irrespective of presence or absence of recurrent ischemic symptoms. Furthermore, changes in lesion severity were assessed quantitatively by an automated edge-detection technique rather than visual analysis. Employing such a study design and follow-up protocol, it was found that the incidence of restenosis in patients with stable coronary artery disease was similar to that of patients with unstable rest angina, irrespective of the type of angiographic definition used.H.E. Luijten, MD, is the recipient of a Research Fellowship from the Dutch Heart Foundation (no. 85–118).K.J. Beatt, MD, MRCP, is the recipient of a Research Fellowship from the British and Dtuch Heart Foundations.     

Plantar lipomatosis, unusual facies, and developmental delay: confirmation of Pierpont syndrome

In 1998, Pierpont et al. reported on two unrelated boys with plantar lipomatosis, unusual facial phenotype, and developmental delay as a possible new MR/MCA syndrome. Here we report on a 2-year-old boy with similar manifestations: axial hypotonia in the first few months, prolonged feeding problems, moderate developmental delay, no speech development, deep palmar and plantar grooves, fat pads at the anteromedial aspect of the heels, and a distinct facial phenotype (high forehead, high anterior hairline, mild midfacial hypoplasia, remarkably narrow and upward slanted palpebral fissures, broad nasal ridge and tip, broad philtrum, bowed upper lip, "pouting" lower lip, full cheeks, and flat occiput). Brain MRI and MR spectroscopy studies showed relatively small frontal lobes, some widening of the lateral and third ventricles, and increased choline levels in the frontal white matter. Cytogenetic studies in lymphocytes and skin fibroblasts and whole genome micro-array CGH failed to show abnormalities. The present patient has a phenotype almost identical to that of the earlier reported children (Pierpont et al. [1998]: Am J Med Genet 75:18-21), which thereby validates this as a separate MR/MCA syndrome, appropriately designated Pierpont syndrome. The cause of the entity remains uncertain, the most likely etiologies being X-linked recessive or autosomal dominant genes.     

Inequalities in oncology care: Economic consequences of high cost drugs

The expenditures for hospital drugs are continuously increasing, and grow much faster than the global hospital budgets do. This explosive growth is caused mainly by a few so-called 'expensive drugs' of which the oncolytics form the main part. The global budgets should stimulate more effective provision of care ('technical efficiency'), however the room for technical efficiency is decreasing. Hospitals thus have to make impossible choices, so that eventually equal access can no longer be guaranteed. If no other policies are applied, health care goals will no longer be met. This paper tries to map the contours of the current problem and its possible solutions. It is time governments take up their responsibility and take back control.     

Vascular endothelial growth factor and blood-brain barrier disruption in tuberculous meningitis

BACKGROUND: Tuberculous meningitis (TBM) is characterized by disruption of the blood-brain barrier (BBB), cerebral edema and increased intracranial pressure (ICP). Vascular endothelial growth factor (VEGF) is a potent vascular permeability factor and a mediator of brain edema. AIMS: To investigate whether in children with TBM disruption of the BBB relates to VEGF production and to assess the effect of corticosteroids on Mycobacterium tuberculosis-induced VEGF production by mononuclear leukocytes. METHODS: Blood and CSF samples were collected from 26 children with stage 2-3 TBM and 20 controls. All patients received antituberculous and adjuvant corticosteroid therapy. Children were evaluated by ICP recording, computerized tomography scanning and outcome assessment at 6 months follow-up. BBB disruption was quantified by cerebrospinal fluid (CSF)-serum albumin ratios. VEGF concentrations were measured by enzyme-linked immunosorbent assay. In vitro human monocytic THP-1 cells were stimulated with M. tuberculosis sonicate or culture supernatant, and VEGF production was measured in the presence or absence of corticosteroids. RESULTS: CSF VEGF concentrations were significantly higher in TBM patients than in the controls and correlated with mononuclear cell counts (r = 0.64; P = 0.001) and CSF-serum albumin ratio (r = 0.49; P = 0.015). CSF VEGF did not significantly correlate with elevated ICP. In vitro induction of VEGF production by M. tuberculosis sonicate or culture supernatant could be completely abrogated by corticosteroid treatment. CONCLUSIONS: Inflammatory cells secrete VEGF during TBM. CSF VEGF correlates with BBB disruption. Inhibition of VEGF may explain part of the clinical effect of adjuvant corticosteroid therapy in TBM.     

Effects of frequent cannabis use on hippocampal activity during an associative memory task.

Interest is growing in the neurotoxic potential of cannabis on human brain function. We studied non-acute effects of frequent cannabis use on hippocampus-dependent associative memory, investigated with functional Magnetic Resonance Imaging (fMRI) in 20 frequent cannabis users and 20 non-users matched for age, gender and IQ. Structural changes in the (para)hippocampal region were measured using voxel-based morphometry (VBM). Cannabis users displayed lower activation than non-users in brain regions involved in associative learning, particularly in the (para)hippocampal regions and the right dorsolateral prefrontal cortex, despite normal performance. VBM-analysis of the (para)hippocampal regions revealed no differences in brain tissue composition between cannabis users and non-users. No relation was found between (para)hippocampal tissue composition and the magnitude of brain activity in the (para)hippocampal area. Therefore, lower brain activation may not signify neurocognitive impairment, but could be the expression of a non-cognitive variable related to frequent cannabis use, for example changes in cerebral perfusion or differences in vigilance.     

A prospective cohort study on sustained effects of low-dose ecstasy use on the brain in new ecstasy users.

It is debated whether ecstasy use has neurotoxic effects on the human brain and what the effects are of a low dose of ecstasy use. We prospectively studied sustained effects (>2 weeks abstinence) of a low dose of ecstasy on the brain in ecstasy-naive volunteers using a combination of advanced MR techniques and self-report questionnaires on psychopathology as part of the NeXT (Netherlands XTC Toxicity) study. Outcomes of proton magnetic resonance spectroscopy (1H-MRS), diffusion tensor imaging (DTI), perfusion-weighted imaging (PWI), and questionnaires on depression, impulsivity, and sensation seeking were compared in 30 subjects (12M, 21.8+/-3.1 years) in two sessions before and after first ecstasy use (1.8+/-1.3 tablets). Interval between baseline and follow-up was on average 8.1+/-6.5 months and time between last ecstasy use and follow-up was 7.7+/-4.4 weeks. Using 1H-MRS, no significant changes were observed in metabolite concentrations of N-acetylaspartate (NAA), choline (Cho), myo-inositol (mI), and creatine (Cr), nor in ratios of NAA, Cho, and mI relative to Cr. However, ecstasy use was followed by a sustained 0.9% increase in fractional anisotropy (FA) in frontoparietal white matter, a 3.4% decrease in apparent diffusion (ADC) in the thalamus and a sustained decrease in relative regional cerebral blood volume (rrCBV) in the thalamus (-6.2%), dorsolateral frontal cortex (-4.0%), and superior parietal cortex (-3.0%) (all significant at p<0.05, paired t-tests). After correction for multiple comparisons, only the rrCBV decrease in the dorsolateral frontal cortex remained significant. We also observed increased impulsivity (+3.7% on the Barratt Impulsiveness Scale) and decreased depression (-28.0% on the Beck Depression Inventory) in novel ecstasy users, although effect sizes were limited and clinical relevance questionable. As no indications were found for structural neuronal damage with the currently used techniques, our data do not support the concern that incidental ecstasy use leads to extensive axonal damage. However, sustained decreases in rrCBV and ADC values may indicate that even low ecstasy doses can induce prolonged vasoconstriction in some brain areas, although it is not known whether this effect is permanent. Additional studies are needed to replicate these findings.